Why exercise is important to your quality of life
Getting enough regular physical exercise is important for everyone’s health. But it’s especially important for people living with bipolar disorder, as the condition itself (and often the medications used to treat it) may affect physical health. For example, people with bipolar disorder have a higher risk of cardiovascular disease1. As well, some of the medications commonly used to manage bipolar disorder have side-effects that may increase your risk for metabolic syndrome, a group of risk factors including abdominal obesity and high blood sugar, blood lipids, blood pressure and cholesterol that can lead to type II diabetes and cardiovascular disease2.
Broadly speaking, physical activity improves cardiovascular health and can help you maintain a healthy weight.
Exercise and depression
For people living with depression, regular exercise has also been shown to improve cardiovascular fitness, mood, and physical and psychological quality of life3,4,5. Studies that have followed individuals over many years show that low levels of physical activity increase one’s risk of developing depression6,7 and links to more severe depression symptoms8. Physical activity has been associated with less suicidal thoughts in many studies9. As a result, regular physical activity is recommended as an important part of treatment for depressive disorders10,11,12.
Specifically for bipolar disorder, a review of the research linked higher levels of physical activity with less depressed symptoms, better quality of life, and increased functioning13. One study followed people living with bipolar disorder for 18 months and linked physical activity with a better prognosis, fewer mood episodes and hospitalizations, lower levels of anxiety, less insomnia, and better functioning in all areas measured (autonomy, work, cognitive function, managing finances, relationships and leisure)14.
Strong evidence exists to support exercise for the management of clinical depression15,16,17. Because of this, depression is the only mental illness in which exercise is recommended as an evidence-based treatment. Exercise is recommended as a stand-alone treatment for mild-moderate depression, and in combination with other treatments (such as medication or talk therapy) for moderate-severe depression10.
If you want to use exercise as a treatment for depression, one recommended ‘dose’ based on existing evidence is 30 minutes, 2-3 times a week, moderate intensity (e.g. walking as if late for a meeting) for a minimum of 9 weeks and supervised (done with an exercise professional or instructor) if possible. If using exercise or physical activity for general health benefits (unless advised otherwise), try to work up to a total of 150 minutes of moderate intensity aerobic exercise per week (e.g., walking, jogging, cycling, swimming); with 2 sessions of muscle strengthening exercises (e.g., lifting weights).
These physical activity guidelines are recommendations. Considerations should be taken for your current activity and fitness levels. These guidelines can also be goals to work up to. The best ‘dose’ of exercise is the one you can stick to. Any movement is better than none, find physical activity you enjoy and will continue to do.
Exercise and bipolar disorder
No guidelines exist in Canada for exercise in treating bipolar disorder, as less is understood about how it can be used to manage mood. However, people living with mental illness including bipolar disorder are at a higher risk for developing health conditions such as diabetes and heart disease and life expectancy may be lower in people with bipolar disorder than in the general population18. Exercise can counter-act these risks19,20. Because of this, exercise is acknowledged as important for general health benefits in managing bipolar disorder21.
While this research on the benefits of exercise is exciting in theory, most people struggle with putting it into practice. Having a sedentary or physically inactive lifestyle is common in people living with bipolar disorder13. This may be explained by the “inactivity trap”—how depression worsens inactivity and inactivity worsens depression22. The symptoms of depression itself—such as fatigue, poor motivation and self-esteem, and negative thinking—make getting out to exercise extremely difficult23,24. Medication side-effects, such as sedation and weight gain, can also be barriers to exercise5.
The limited research on physical activity and mania suggest a different picture. While exercise can improve symptoms of depression (while depression makes it harder to exercise), in some people, exercise may potentially exacerbate symptoms of mania (while mania can make you more motivated and driven to exercise)26,27.
How you can take action
One of the major obstacles for people living with mood disorders is that mood symptoms often miscue your actual needs for activity. So when you are experiencing manic or hypomanic symptoms, you feel like excessively exercising or activating, even though this may push you higher. And when you’re depressed, you feel like being inactive, even though this makes depression worse. Research has shown that during a manic or hypomanic phase people with bipolar disorder are likely to set exercise goals that are too high and unsustainable (e.g., “work out for two hours every day”) and during depressive phases, people set very low goals (e.g., “walk to refrigerator for snack”)26. A behavioural approach to this problem is ‘opposite action’—that is, when your mood symptoms are miscuing you to do unhelpful behaviors that only make symptoms worse, practice doing the opposite (e.g. when depression symptoms make you want to stay in bed, schedule in activity even though you don’t feel like it; or when manic symptoms push you to want to be active for hours, set limits and instead schedule in rest periods, even when it doesn’t feel like you need them).
The first step to adding more physical activity into your life is to create a fitness plan that works for you. It’s important to find activities that you enjoy to help make physical activity something you look forward to, rather than a chore. Think of other ways you can make this new habit rewarding, such as having social support or creating an environment that encourages exercise (such as giving yourself a reward when you exercise or getting a positive response from others). Exercising outdoors, in nature or green spaces may be particularly beneficial8.
Another important aspect of increasing your level of physical exercise is to set goals that are realistic so they can be achieved. It doesn’t help to set the bar too high, like people sometimes do when making New Year’s resolutions. If you set your goals too high, you likely won’t be able to continue exercising at this level for more than a few weeks and then you may feel discouraged, or even injure yourself. You are likely to be more successful if you set a small exercise goal and then, once it feels like something you can keep doing regularly, gradually increase it until you reach a healthy exercise level.
New behaviours are a lot easier to stick with once a routine has been established. For example, you are much more likely to walk every morning if you have the routine of walking with a friend at the same time every day, so it becomes as much of a habit as brushing your teeth. Routine can also be important when mood symptoms are miscuing your desire to exercise. If a routine is set, it can be helpful to stick to it regardless of how your mood symptoms make you feel. Exercise can also help structure your day, which can help regulate mood27,29.
It’s important to look at each of the things that may prevent you from starting and maintaining your fitness routine and see if you can problem-solve around each one. If motivation seems to be the problem, it can be helpful to write out a pros and cons list of exercising versus remaining inactive. Also, it can be helpful to challenge negative thinking patterns related to starting a new routine (e.g., all-or-nothing thinking, such as, “Since I missed my walk today, I might as well give up as I will never be able to become physically active”).
Remember, it’s important to check in with your healthcare provider to ensure that it’s safe to go ahead with a new exercise plan before you begin. You could bring the exercise and depression toolkit (www.exerciseanddepression.ca) as a starting point for discussing a plan to exercise more.
- Hayes, J. F., Miles, J., Walters, K., King, M., & Osborn, D. P. J. (2015). A systematic review and meta-analysis of premature mortality in bipolar affective disorder. Acta Psychiatrica Scandinavica, 131(6), 417-425. doi:10.1111/acps.12408
- De Almeida, K.M., Moreira, C.L., & Lafer, B. (2012). Metabolic syndrome and bipolar disorder: What should psychiatrists know? CNS Neuroscience and Therapeutics, 18: 160–166.
- Stubbs, B., Rosenbaum, S., Vancampfort, D., Ward, P.B. , Schuch, F.B. (2016). Exercise improves cardiorespiratory fitness in people with depression: a meta-analysis of randomized control trials. Journal of Affective Disorders, 190:249-253.
- Schuch, F.B., Vancampfort, D., Rosenbaum, S., Richards, J., Ward, P.B., Stubbs, B. (2016). Exercise improves physical and psychological quality of life in people with depression: a meta-analysis including the evaluation of control group response. Psychiatry Research, 241:47.
- Harris, A.H., Cronkite, R., & Moos, R. (2006). Physical activity, exercise coping, and depression in a 10 year cohort study of depressed patients. Journal of Affective Disorders, 93: 79–85.
- Mammen, G., and Faulkner, G. (2013). Physical activity and the prevention of depression: as systemic review of prospective studies. Amercian Journal of Preventative Medicine, 45:649-657.
- McKercher, C., Sanderson, K., Schmidt, M.D., Otahal, P., Patton, G.C., Dwyer, T. , Venn, A.J. (2014). Physical activity patterns and risk of depression in young adulthood: a 20-year cohort study since childhood. Social Psychiatry and Psychiatric Epidemioliology, 49:1823-1834.
- Gudmundsson, P., Lindwall, M. , Gustafson, D.R., Ostling, S. , Hallstrom, T. , Waern, M., Skoog, I. (2015). Longitudinal associations between physical activity and depression scores in Swedish women followed 32 years. Acta Psychiatrica Scandinavia, 132: 451-458.
- Vancampfort, G. D., Hallgren, M., Firth, J., Rosenbaum, S., Schuch, F.B., Mugisha, J., Probst, M., Van Damme, T., Carvalho, A.F. , Stubbs, B. (2018). Physical activity and suicidal ideation: a systematic review and meta-analysis. Journal of Affective Disorders, 225:438-448.
- Ravindran, A.V., Balneaves L.G., Faulkner, G., et al. (2016). CANMAT Depression Work Group. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 5. Complementary and alternative medical treatments. Canadian Journal of Psychiatry, 61:576-87.
- Malhi, G.S., Bassett, D., Boyce, P., et al. (2015). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry, 49:1087–206.
- Cleare, A., Pariante, C.M., Young, A.H., et al. Members of the Consensus Meeting (2015). Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines. Journal of Psychopharmacology, 29:459–525.
- Melo, M. C., Daher, E. F., Albuquerque, S. G., & de Bruin, V. M. (2016). Exercise in bipolar patients: A systematic review. Journal of Affective Disorders, 198, 32-38.
- Melo, M., Garcia, R. F., de Araújo, C., Rangel, D. M., de Bruin, P., & de Bruin, V. (2019). Physical activity as prognostic factor for bipolar disorder: An 18-month prospective study. Journal of affective disorders, 251, 100–106.
- Josefsson, T., Lindwall, M., Archer, T. (2014). Physical exercise intervention in depressive disorders: Meta-analysis and systematic review. Scandinavian Journal of Medicine & Science in Sports, 24, 259-272.
- Krogh, J., Hjorthøj, C., Speyer, H., Gluud, C., & Nordentoft, M. (2017). Exercise for patients with major depression: a systematic review with meta-analysis and trial sequential analysis. British Medical Journal open, 7(9), e014820.
- Morres, I. D., Hatzigeorgiadis, A., Stathi, A., Comoutos, N., Arpin‐Cribbie, C., Krommidas, C., & Theodorakis, Y. (2019). Aerobic exercise for adult patients with major depressive disorder in mental health services: A systematic review and meta‐analysis. Depression and anxiety, 36(1).
- Chesney E, Goodwin GM, Fazel S. (2014) Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry, 13: 153–60.
- Richardson, C. R., Faulkner, G., McDevitt, J., Skrinar, G. S., Hutchinson, D. S., & Piette, J. D. (2005). Integrating physical activity into mental health services for persons with serious mental illness. Psychiatric Services, 56(3), 324-331.
- Rosenbaum, S., Tiedemann, A., Sherrington, C., Curtis, J., & Ward, P. B. (2014). Physical activity interventions for people with mental illness: a systematic review and meta-analysis. Journal of Clinical Psychiatry, 75, 964–974.
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- Carpiniello, F.B., Primavera, D., Pilu, A., Vaccargiu, N., Pinna, F. (2013). Physical activity and mental disorders: a case-control study on attitudes, preferences and perceived barriers. Italy Journal of Mental Health, 22:492-500.
- Pereira, C.S., Padoan, C.S., Garcia, L.F., Patusco, L., Magalhaes, P.V. (2019). Barriers and facilitators perceived by people with bipolar disorder for the practice of exercise: a qualitative study. Trends in Psychiatry and Psychotherapy. 41 (1):1-8.
- Roberts, S.H., Bailey, J.E. (2011). Incentives and barriers to lifestyle interventions for people with severe mental illness: a narrative synthesis of quantitative, qualitative and mixed methods studies. Journal of Advanced Nursing, 67:690-708.
- Sylvia, L.G., Friedman, E.S., Kocsis, J., et al. (2013). Association of exercise with quality of life and mood symptoms in a comparative effectiveness study of bipolar disorder. Journal of Affective Disorders, 151: 722-727.
- Wright, K., Armstrong, T., Taylor, A., Dean, S. (2012). “It’s a double edged sword”: a qualitative analysis of the experiences of exercise amongst people with Bipolar Disorder. Journal of Affective Disorders, 136: 634–642.
- Bratman GN, Anderson CB, Berman MG, et al. Nature and mental health: An ecosystem service perspective. Science Advances. 2019;5(7). doi:10.1126/sciadv.aax0903
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